Sep 8, 2018
AP: Welcome to the Growing Healthy Podcast. Today we are
fortunate to have Dr. Kelsey Mills with us to talk about
Menopause!! Dr. Mills is an obstetrician and gynecologist who
has extra training in the Hot topic of Menopause! Thanks for
joining us Kelsey!
KM: Thanks Alicia, it is my pleasure to chat with you
today! This is a topic that can get women all fired
AP: Why don’t we start with the basics; what is
KM: That’s a great place to start. Menopause is defined
as the permanent absence of menstrual periods for one year, in the
absence of other reasons for a period to stop, such as pregnancy.
We have had a couple women tricked into thinking they were in
menopause when in fact they were pregnant!
AP: What a surprise that would be!!! Can you tell us a
little more about Menopause.
KM: The average age of menopause in Canada is 51.4 and
anything after 40 is in fact in the realm of normal. If a woman
enters menopause under the age of 40, we search for other diseases,
or reasons why that could happen. In natural menopause, a woman
stops having periods because her ovaries have essentially used up
their pool of eggs (oocytes) and are no longer ovulating each
month. Therefore, there isn’t an episode of bleeding that follows
ovulation, so all bleeding stops. When women don’t ovulate anymore,
there are much lower levels of circulating estrogens in their body
which may or may not result in menopausal symptoms.
AP: But the transition is not necessarily an on/off
switch is it....
KM: Nope...it sure isn’t! On average, women start to
experience symptoms of perimenopause for 4-5 years prior to not
getting a menstrual period any more. These symptoms can
include irregular or erratic cycles, cycles that fluctuate in
heaviness (one month light, one month very heavy), mood changes,
hot flashes, night sweats, sleep disturbances and vaginal
AP: I often have women coming in around that time with
musculoskeletal complaints as well....
KM: There are some other common concerns that happen around
the time of menopause and certainly increase with aging, like
“brain fog”, memory changes, hair loss, weight gain, and muscle and
AP: So lets talk about the menopause-specific symptoms
a bit more and how we can manage them.
KM: Great. So I find that the symptom that bothers
women the most, are what we call “vasomotor symptoms” which include
the hot flashes and night sweats. We know that about 80% of women
in the menopausal transition experience hot flashes, but
unfortunately only about 20% of those women will seek medical
attention for them. Studies have shown that women find it difficult
to discuss menopausal concerns with their primary care providers,
and in particular find discussing vulvo-vaginal or sexual symptoms
to be the most challenging. But back to hot flashes, these are
generally described as a feeling of heat starting in the chest and
then spreading over the upper body, face and neck. They can be
accompanied by heart palpitations and sweating, and they generally
last for 2-4 minutes. Hot flashes are so interesting, because some
women never experience them, and some women will flash several
times an hour in menopause. Hot flashes can also be different woman
to woman; some women describe a prickling or skin-crawling
sensation, some women describe a sense of impending doom! This is
serious stuff. Menopause researchers used to believe that hot
flashes only lasted for 4-5 years, but we now know that they can
last much longer, perhaps 8 years on average, and some women will
flash for the remainder of their life.
AP: Are there any factors that can make it more likely that
women will have worse hot flashes?
KM: Well we know obesity and smoking both increase the risk
of hot flashes. Interestingly, certain ethnic backgrounds, such as
being of African descent, may make a woman more likely to have hot
AP: Hot flashes can happen at night as well....often
drenching beds with sweat etc. and this leads into our next
symptoms of menopause....sleep disturbance! We know that
about 40% of women struggle with sleep in the menopause transition
- this can be related to hot flashes, or our next topic....mood
changes - namely depression. They can also be related to
things like restless legs or sleep apnea - so please make sure you
talk to your family doctor if you are having sleep disturbances as
there may be some testing we need to do and something we can help
KM: It is true...there are so many interconnected pieces
within menopause, but we can't blame everything on it! The
mood changes can often be attributed to the perimenopausal and
early post menopausal time, especially in women who have not had
mood disturbances before, and in these women, we often see it
improve 1-2 years after menopause. Women with pre-existing
anxiety and depression are at the most risk for worsening mood
issues during the menopausal transition. Probably the number one
descriptor of mood changes that I hear is an increase in a women’s
“irritability”. But the midlife can be a very stressful time for
women, and there are many reasons for mood changes in the midlife
which may not be all attributable to hormonal changes.
AP: Vaginal dryness is often a complaint women have with
menopause, can you speak about that a bit?
KM: Absolutely. This is a really important topic that I wish
women felt more supported to discuss. Estrogens play an important
role in our bodies and women can make several different kinds of
estrogens. Tissues in a women’s vulva, vagina, lower urinary tract
and bladder are very sensitive to the effects of estrogens. When
those estrogens are withdrawn in menopause, this can result in
something we term “genitourinary syndrome of menopause” which is a
fancy name for when all those tissues become drier and less
elastic. This can result in itching, bleeding, having to urinate
frequently or urgently, getting recurrent urinary infections, and
having pain with sexual intercourse. Unlike many other menopausal
symptoms, the genitourinary symptoms often start later into
menopause and will progress as a woman ages.
AP: And I also think it is important to note, that these
symptoms, especially the itchiness and pain, are not always simply
due to menopause, so again it is important to see your care
provider to ensure it is not something else causing this!
KM: Indeed! These changes can be very uncomfortable and
distressing for women....so please do not suffer
unnecessarily...come talk to us...because we can help!!! And I want
to take this moment to point out that although some women may bleed
in menopause because of tissue dryness, post-menopausal bleeding is
never normal and other sinister causes must be ruled out. Please
speak to your doctor if you are menopausal and start bleeding
again. Your doctor can help you with investigations to rule out
worrisome causes of post-menopausal bleeding, like certain
AP: That’s a great reminder. Well lets chat about what
we can do to help women going through menopause….
KM: First and foremost let’s talk about lifestyle
modifications that women can do to help manage the menopausal
transition. Anything that cools us down can help with hot
flashes - having the room at a lower temperature, using a fan,
using moisture wicking sheets or clothes, dressing in layers that
can easily be removed and avoiding triggers like spicy food or
stress can all help. Alcohol is a huge hot flash trigger for many
of my patients. And alcohol contains a lot of empty calories, so
cutting back can help with weight reduction and vasomotor symptoms.
We also know that excessive alcohol consumption is a risk factor
for breast cancer. So that’s another important reason to stop
excessive drinking. Back to the notion of weight loss, if a woman
is carrying extra weight, losing weight may reduce menopausal
symptoms. Another very important point is that quitting smoking can
have a large impact on vasomotor symptoms, bone health and overall
health for women.
AP: Beneficial for menopause and beyond!!! Other
changes that can help with mood changes, joint achiness and sleep
disturbance include staying well hydrated, getting regular
exercise, eating healthily and maintaining good sleep hygiene.
Pulling in your support system, through what can be a challenging
period in your life, is never a bad idea!! Mindfulness-based stress
reduction is another tool that many women going through menopause,
or other stressful times, find to be very helpful!
KM: Indeed...but most women who come to see me are suffering
more than these measures can help, and that is why we often have a
conversation about medications.
AP: My understanding is that when it comes to
medications, you treat based on symptom severity, so not every
treatment plan is the same...is that correct?
KM: Exactly. Women are so unique. Remember that there are
some menopausal women who have never had a hot flash, and some who
suffer hourly! If someone has vulvo-vaginal issues, and no
other symptoms, then I will treat that, but if a woman has multiple
issues the treatment plan might be much different!
AP: Shall we talk about treatment then?
KM: Yes, let’s do it. The simplest symptom to treat is
vaginal dryness. Using a good lubricant with intercourse can
be enough for some women’s concerns, but others may benefit from a
vaginal moisturizer or local vaginal estrogen to help with their
symptoms. Vaginal estrogens in Canada can come in the form of
a cream, a vaginal suppository, or a vaginal ring that is worn
daily for 3 months. Local estrogens are extremely safe and there is
very minimal systemic absorption of these medications. In general,
vaginal estrogens are safe for all women. They do not carry an
increased risk of blood clot, or stroke. If a woman has had breast
cancer, then this is a bigger conversation and I encourage her to
discuss the role of local estrogens with her gynecologist and
AP: So I have heard lots about vaginal
rejuvenation.....lasers and vaginas....seems like a dangerous
KM: Using lasers to treat vulvo-vaginal symptoms is a
relatively new player in the menopause realm. And this is different
from using lasers or surgery for cosmetic enhancement, or
“rejuvenation”, of the vulva and vagina. I strongly advise women
against cosmetic changes their vulva and vagina. But that is
another topic for another day! Back to menopause, there is
ongoing research looking into the safety, efficacy and long-term
consequences of using a laser to treat vaginal symptoms, such as
dryness, in menopause. Currently, vaginal laser treatments are not
covered by Pharmacare or MSP, so women pay privately to use this
device. I look forward to seeing further studies in this area
so I can help women decide if investing in this treatment is
appropriate and safe for them.
AP: So what if women have hot flashes as well? Will the
vaginal estrogen help those?
KM: Good question Alicia. Hot flashes are treated with either
hormonal or non-hormonal systemic medications. If hot flashes
or night sweats are bothering the woman, then we will have a
discussion around treatment options. The most common
treatment is an estrogen and progesterone. There are
certainly some women who should not take these medications for
medical reasons, which is one of the reasons it is so important to
have a good conversation with your care provider prior to starting
AP: Now you said estrogen and progesterone....isn't just
estrogen the problem?
KM: In general, menopause experts believe that vasomotor
symptoms are best treated with systemic estrogen. But, if we give a
woman with a uterus only estrogen, we increase her risk of
endometrial, or uterine cancer. The endometrium is the lining of
the uterus that sloughs off every month when a woman has a
period. The reason that it sloughs off, and just doesn’t keep
growing and growing is progesterone. So to protect the lining
of the uterus from thickening into a potential cancer, we use
progesterone to keep the endometrium thin and healthy.
AP: I have it on good authority that progesterone can help
with sleep as well!
KM: Certain forms, like micronized progesterone, are better
for this than others! Many women find progesterone to be sedating,
and so I always recommend that women take their progesterone at
night before bed.
AP: So what is the goal with Hormone therapy?
KM: Our goal is to use the lowest dose, for an appropriate
duration, to manage a woman's symptoms. This is individualized
based on the woman’s symptoms.
AP: So you are not trying to get to a certain number in their
KM: No...in fact we know that symptoms are not correlated
with blood hormone levels, and I explain that to my patients by
saying that a woman who has terrible hot flashes, and a woman who
doesn’t know what a hot flash feels like, may have the same hormone
levels! So we individualize the amount of hormone that women need
(or don’t need!) based on how feel her symptoms are being
AP: So why are some practitioners checking levels, and
compounding creams specific to those numbers....
KM: That’s an interesting question Alicia. Compounding
hormones refers to mixing hormones in a specific base or oral
preparation and then applying or ingesting those hormones. I worry
about what exactly my patients are receiving when those hormones
are mixed, because unlike pharmaceutical grade hormones (like
pills, patches, or gels), no one is doing testing on those creams
to check for components, quantities, purity, or to do batch
testing. We also know that progesterone is not absorbed well across
the skin, so I have major concerns when my patients come to me on
progesterone creams and estrogen. No major professional
organization advocates for the use of compounded hormones. Often
compounded hormones are very expensive as well.
AP: So save your money and buy a new pair of shoes?
KM: Or hormones that work!
AP: Back to business.....So how can the estrogen and
progesterone be taken?
KM: Well, once a woman identifies that she would like
treatment for her vasomotor symptoms, we first consider reasons why
it may not be safe to take systemic hormones. Although hormone
therapy is extremely safe, we know that in certain cases, using
menopausal hormone therapy may increase women’s chances of a blood
clot, stroke and breast cancer. This is particularly true of older
women, for example, over the age of 60 who have multiple health
problems. After evaluating these risks, we generally prefer
transdermal estrogen, which is estrogen that is given through the
skin in a gel or patch. We believe that this lowers the stroke and
blood clot risk associated with estrogens. Most of my patients (if
they have a uterus), will use a micronized progesterone to protect
their uterus and help with sleep. The exact doses and types of
hormone therapy are often individualized to the woman.
AP: So we know that the HRT can help with some of the mood
disturbance, but what if that is the main complaint as opposed to
KM: Well this is a topic you are probably better at managing
than I am!! Treat the mood disturbance!! Although there are a few
antidepressants that have shown some efficacy in improving hot
flashes as well, so if women are suffering from mood disturbance
and hot flashes and are not able to take HRT for some reason, we
will try one of these medications to help manage both. These
medications include Paroxetine, Venlafaxine and
Desvenlafaxine. Now if you are on an antidepressant and not
significantly affected by hot flashes, I would not switch to one of
these, but if you have hot flashes, and your doctor is talking
about starting an antidepressant, you could consider starting with
one of these. Mood changes in menopause are not an indication for
starting hormone therapy.
AP: Right, and remembering managing any mood disturbance the
best place to start is talking and lifestyle optimization! So
talk to your doctor, talk to a counsellor or friend if possible,
pull in your support system. Get outdoors and exercise, make
sure you are following a healthy way of eating, staying hydrated
and minimizing alcohol.
KM: Before we wrap up I just wanted to chat a bit about
"natural/herbal" medication in menopause care because this is
something I see a lot of. In general, I tell women that if they are
using a herbal supplement and they find it helpful, then it is
likely a fairly low risk thing to do. The studies show that most
herbal supplements in menopause have a strong placebo effect, and
women generally find their symptoms return around the 3 month mark.
I see a lot of women who have tried all of the herbal supplements
and not had relief of their symptoms. I once had a patient come to
my office with a laundry basket full of supplements! She had tried
everything, and was still having terrible hot flashes. This is
common and your care provider can help you discuss medical options
to help manage your symptoms more effectively.
AP: Great! Well thanks for coming and chatting about
Menopause with me....something to look forward to in the coming
Keep on Growing Healthy.